NABET CRITERIA FOR ACCREDITATION OF AWARENESS COURSE · PDF fileNABET Criteria for...

NABET Criteria for Accreditation of Awareness Course on Hospitals and Healthcare Providers Accreditation (NABH)

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NABET CRITERIA FOR ACCREDITATION OF

AWARENESS COURSE ON HOSPITAL AND HEALTHCARE PROVIDERS (NABH)


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Section 1: INTRODUCTION 1.1 Quality Council of India (QCI), the national accreditation body, has been established jointly by

the Government of India and the Indian Industry represented by the three premier industry associations, Associated Chambers of Commerce and Industry of India (ASSOCHAM), Confederation of Indian Industry (CII) and Federation of Indian Chambers of Commerce and Industry (FICCI). It is a non-profit, autonomous organisation.

1.2 National Accreditation Board for Education and Training (NABET), one of the Boards

functioning under QCI, offers registration to the professionals in the relevant areas i.e. Quality, Environment, Food Safety, Occupational Health etc.

1.3 NABET is a member of International Personnel Certification Association (IPC), an international

association of similar national bodies worldwide. 1.4 NABET is now offering registration of “Awareness Programme on Hospitals and Healthcare

Service Providers Accreditation (NABH)”. Scope

The programme is meant for all levels of personnel of Hospitals and Healthcare Providers.

The programme is also useful for Hospitals and Healthcare Providers clients, personnel of regulatory authorities and accreditation bodies who may use the knowledge gained in conforming or recognising the competency of Hospitals and Healthcare Providers.


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Section – 1 COURSE OBJECTIVES

1.1 Learning Objectives Learning objectives describe what participants must be able to do so by the end of this course. Participants need to demonstrate acceptable performance in all of these areas in order to complete the course successfully and the training course provider will need to demonstrate a factual and objective approach to the assessment of participant performance against the following. 1.2 General

A participant who actively participates in the programme shall be able to describe the purpose of a Management System as per NABH standards and its role in helping Hospitals and Healthcare Providers to operate with increased effectiveness, consistency and customer satisfaction.

1.3 A participant who actively participates in the programme shall be able to:

i) Explain the essence of NABH Accreditation standards.

ii) Describe the steps involved in Hospital and Healthcare Providers Accreditation.

iii) Present the benefits of Hospital and Healthcare Providers Accreditation.

iv) Describe all the requirements for the competence of Hospital and Healthcare Providers as specified in NABH Standards (NABHS).

v) Understand and describe the intent and requirements of each element of NABHS.

vi) Describe the documents required as per NABHS and their control mechanism. vii) Understand need for documentation and maintenance of records as evidence for further

reference, the difference between documents and records and the procedure for maintenance and control of records.

viii) Describe the monitoring processes necessary for the Hospital and Healthcare Providers.

1.4 The training course provider may develop more detailed learning objectives as

appropriate. 1.5 Participants’ achievement of the learning objectives shall be measured by the training

provider.


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Section – 2 COURSE CONTENT

Early in the course presentation, the course provider shall provide to the participants a description of the course format, participant responsibilities, how the participant will be evaluated and the basis for each type of evaluation. The course shall cover:

a) all aspects defined in the Course Objectives and b) Local requirements and guidelines of statutory bodies, culture, practices as applicable to

Hospitals and Healthcare Providers and the application of NABH standards adequately.


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Section – 3 COURSE STRUCTURE, TRAINING METHODS AND FACILITIES 3.1 Duration 3.1.1 The total course time devoted to direct instruction and to assigned team and individual

activities shall be at least 12 hours. 3.1.2 If the course is given through interpreters, the time shall be increased as required to meet the

learning objectives 3.1.3 Time devoted to the written examination, meals, breaks or other free time is not included in

the calculation of the course duration. 3.1.4 The course shall be presented during two consecutive days, unless otherwise authorized by

NABET. 3.2 Training Methods 3.2.1 Training courses shall be designed to have a high degree of interaction between participants

and instructors. Training methods shall seek to involve and engage participants throughout the duration of the course.

3.2.2 The training course shall include knowledge based sessions (to facilitate understanding of

concepts) supported by relevant examples. These examples must be relevant to the needs of the audience. Specific examples shall be given relating to variety of processes depending upon size, complexity and specialized competence of the Hospitals and Healthcare Providers.

3.2.3 Knowledge based sessions may be instructor led, but shall allow for some interaction with

participants enabling instructors to test learning and participants to clarify their understanding as required.

3.2.4 Methods for validating participant achievement of the learning objectives and for providing

timely feedback shall be included in the course. 3.2.5 Instructors shall demonstrate effective management of the course, including attention to time

schedule, course content, requirements of the standard, instructor conduct and other course requirements.

3.2.6 Training aids such as videos that are directly relevant may be used to supplement the training

by the instructors. These may be commercial training videos or videos produced during the course to record and review the performance of participants. No more than two hours of the total course time may be devoted to non-interactive, passive training aids.

3.3 Class size; Attendance 3.3.1 The number of participants in a class shall be no greater than thirty nor fewer than four. 3.3.2 Participants shall be required to be in attendance for the full duration of the course. 3.4 Instructors 3.4.1 The Instructor/s shall have at least five years of working in the field of Healthcare. The

instructor/s shall have at least successfully completed Lead Auditor Training Course for Hospitals and Healthcare Providers.


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3.4.2 The Instructor/s shall be actively involved in instruction and evaluation for the full duration of the course.

3.4.3 Additional resource people or trainee instructors may be used for specific subjects or

activities, however the lead instructor/s remain responsible for the entire course offering. 3.4.4 When specific activities (ex. Written quizzes, use of video aids, etc.) involve neither instruction

nor evaluation and do not require the availability of the instructors for explanation, clarification or advice, any one instructor need be present.

3.4.5 Well qualified and experienced Resource Persons associated with the Hospital/Healthcare

Industry shall present the topics in the programme. (Refer to Section 5.4 guidelines for instruction)

3.5 Course Materials 3.5.1 Each participant shall be provided with a complete set of course notes to supplement the

training program. 3.5.2 The documents included in the course notes shall themselves illustrate good organization,

layout and document management practices, including document revision level and appropriate page numbering.

3.5.3 The set of course notes shall prominently identify the approved course provider (ex. on cover

page etc.). 3.5.4 The participant notes shall cover each session and shall include all important points of the

learning objective(s) being covered. 3.5.5 Examples of typical documents, reports and forms shall be included. 3.5.6 Each participant shall preferably be provided a copy of the current version of published NABH

Standard. 3.5.7 If the standard is not supplied as part of the course notes each participant shall be required to

take a copy to the course. A copy shall be made available for loan to any participant who does not have one.

3.6 Facility and Training Environment 3.6.1 The course provider shall ensure that suitable facilities for training are provided, including

classroom, audio-visual and other training equipment, and facilities for team activities. 3.6.2 Ambience and the work environment during course shall be such that would facilitate free and

frank discussions specially for the team activities and group exercises.


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Section – 4 EVALUATION OF PARTICIPANTS Each participant may be evaluated using either or both of the following two independent elements towards successful completion of their course: a) the continual evaluation by the instructors of each participant’s achievement of the learning

objectives detailed as above and/or b) a written examination that tests participants’ ability to apply the knowledge gained during the

course. 4.1 Continuous Evaluation The continuous evaluation shall be documented and shall evaluate each participant’s:

a) achievement of the learning objectives b) attendance and punctuality during the course

Each participant’s performance shall be reviewed at the end of each day by the instructor(s). A daily grade shall be assigned for each participant, reflecting the assessment of instructor/s. Course instructor/s shall identify participants who appear to be having difficulty in achieving the learning objectives or who are not performing adequately in course activities. Such participants shall be informed privately and in a timely manner of the instructor’s observations and be given opportunity to improve. A participant who fails the continual evaluation must satisfactorily complete another full training course before being eligible to receive a certificate of successful completion. 4.2 Written examination 4.2.1 The written examination shall evaluate the participants’ comprehension of the NABH

standards and its application. The time allotted for taking the examination shall be one hour. Strict adherence to the time limit shall be maintained.

4.2.2 The instructor may allow a participant with particular disability that adversely affects the

participant’s capability to complete the examination in the allotted time up to 30 minutes additional time for taking the written examination. Any such allowance shall be indicated in the records of the course or of the examination with supporting reasons.

4.2.3 At least 75% of the examination grade shall be based on questions that require written

responses which test the participant’s ability to understand, analyze and apply the NABH standards.

4.2.4 The remainder of the examination grade shall be based on multiple choices, true/false or

short answer questions. The minimum passing grade shall be 70%. 4.2.5 The only reference material allowed during the examination is a copy of the NABH standard

and Course material. 4.2.6 Copies of the examination questions (other than those in an example examination paper),

examination papers, solutions or completed examination papers shall not be supplied to any participant or any other party (except to the approval body) for any reason.

4.2.7 Training course provider shall ensure that the instructor(s) for any given course presentation

and/or designated authority are not aware of the examination paper to be used for that presentation.

4.2.8 At least one instructor of the course must be present during the examination.


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Section – 5 TRAINING COURSE ADMINISTRATION

5.1 Administrative Procedures 5.1.1 The course provider’s Quality Management System should be based on the ISO9001:2000

standard. 5.1.2 The course provider shall develop and maintain documented procedures for the effective

administration of the course in line with ISO 9001:2000. Areas covered shall include:

i The design, development and evaluation of course materials and documentation to ensure conformity with the current NABET criteria

ii Presentation of the course

iii The control of course publicity and advertising

iv A document control system for the maintenance and updating of procedures and course notes.

v The criteria for selecting course instructors, procedures for their initial training, evaluation of their delivery of the course and ongoing review of performance.

vi Management reviews of the course.

vii Records of individual participants and each course offering, including analysis of statistics.

viii Participant evaluation procedure, including pass/fail decisions.

ix Operation and conduct of the examination and re-examination, including security and confidentiality of examination questions, answers and marked papers.

x Issue and withdrawal of certificates

xi Storage and eventual disposal of marked papers and continuous assessment records.

xii Methods such as statistical techniques used to analyze and improve participant evaluations, instructors’ performance and overall course performance.

xiii Notifying NABET of significant changes to the course before they are implemented.

xiv Complaints and appeals.

5.2 Records

i The course provider shall maintain records to demonstrate conformance to the NABET requirements.

ii Records shall be maintained in English. iii Records may be in the form of any type of media, such as hard copy or electronic media. iv These records shall be maintained for at least three years. v These records shall be made available to NABET. vi The records for each course presentation shall include:

a. Venue, dates, related advertisement and promotional literature b. Names of instruction team members, with their auditor registration status at the time

of that course presentation, trainee instructors, observers. c. Identification of the specific issue (revision level) of the course documentation used. d. Identification of the examination paper used


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e. Names of all participants who attended the course, together with the continuous evaluation results and the examination results for each participant

f. All copies of marked examination papers, continuous evaluation forms and related summaries

g. The percentage of participants that successfully completed the course h. Unique identification number of each certificate of successful completion and the

name of the participant to whom it was issued. 5.3 Management Review 5.3.1 The management of the course provider shall review its administrative procedures at least

annually and shall maintain records of these reviews for at least three years. 5.3.2 The management shall review the following at least annually for effectiveness and conformity:

a. Actions outstanding from previous management review meetings b. Actions resulting from surveillance by the approval body c. Administrative procedures d. Course design e. Course presentation f. Performance of instructors and future training/CPD needs g. Complaints and appeals h. Analysis of participant feedback and pass/fail rates

5.4 Instructors 5.4.1 The Instructor/s shall have at least five years of working in the field of Healthcare. The

instructor/s shall have at least successfully completed NABH Assessor Training Course. 5.4.2 The Instructor/s shall be actively involved in instruction and evaluation for the full duration of

the course. 5.4.3 Additional resource people or trainee instructors may be used for specific subjects or

activities, however the lead instructor/s remain responsible for the entire course offering. 5.4.4 When specific activities (ex. Written quizzes, use of video aids, etc.) involve neither instruction

nor evaluation and do not require the availability of the instructors for explanation, clarification or advice, any one instructor need be present.

5.4.5 Well qualified and experienced Resource Persons associated with the Hospital/Healthcare

Industry shall present the topics in the programme. 5.4.6 All Instructors shall have the following competence:

a. ability to facilitate the learning of appropriate knowledge on NABH standards b. familiarity with the current course materials and documentation c. good communication skills to be able to impart necessary knowledge to participants d. have knowledge of current practices and of relevant standards e. familiarity with the applicable international and national regulations

5.4.7 Before allowing instructors to present a course, training providers shall first ensure that

he/she has acquired the competence as defined above. As a minimum this shall also involve the instructor (all the following):

a. participating either as a participant or observer on a complete presentation of the

training organization’s course b. participating as an instructor under the supervision of a trained instructor for a

minimum of one course covering all sessions of the course c. being monitored by the training provider presenting and managing the course


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5.4.8 The Instructors must be provided with all necessary materials and supporting documentation

to plan, manage and present the course and assess participant’s performance according to defined requirements.

5.4.9 The course provider shall have documented procedures to:

a. selection of Instructors, on the basis of their competence, qualifications, experience and training

b. Initially assessing the conduct of Instructors during courses and subsequently monitoring their performance.

5.4.10 These procedures shall include monitoring and review, at least annually, of each instructor’s

performance. Records of these reviews shall be maintained by the course provider. 5.4.11 Where there have been no previous presentations of a course (i.e. where the course provider

is seeking initial approval), the course provider shall have documented evidence of fulfillment of the competence requirements of the instructors before the initial presentation.

Detailed resumes of all the Instructors should be sent along with the application to NABET.

Any additions in the list of instructors should be communicated to NABET immediately for approval before participation of any instructor in the course delivery.

5.5 Certificates 5.5.1 A certificate of “successful completion” shall be provided to each participant who has passed

either or both the written examination and the continuous evaluation.

The certificate shall:

a. Clearly state that the course is registered by NABET b. Include the NABET registration mark c. Include a unique identification number for each certificate d. Clearly show the name of the course provider, as it is registered by NABET e. Identify the course by course title, course number and dates of presentation of the

course f. Include the name of the participant, in the same form that the participant has

registered for the programme g. State that the participant named has successfully completed the course h. Include all information on a single side of the certificate

5.5.2 The wording of any certificates of “attendance” shall make it clearly apparent that the

participant has only attended the course. There shall be no implication of successful completion.

5.5.3 Participants shall be informed by the course provider that certificates of “Successful

completion “and “Attendance” do not in itself satisfy the requirements for auditor registration. 5.5.4 The design and content of the certificate of “successful completion” and the certificate of

“attendance”, and any changes thereto, shall be approved by NABET. 5.5.5 No alterations shall be made in the certificate without prior approval of NABET.


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5.6 Complaints and Appeals

5.6.1 The course provider shall have documented procedures for handling & disposal of complaints within a reasonable time.

5.6.2 The course provider shall have a documented appeal mechanism for handling appeals

against its decisions & disposal of appeals within a reasonable time. 5.6.3 The documented procedure shall include provision for corrective and/or preventive action to

be taken if required as a result of any complaint or appeal. The procedures shall include the potential involvement of NABET in unresolved complaints or appeals.

5.6.4 The course provider shall inform all participants of the right to make a complaint or an appeal

and shall provide written details of the process for doing so, on request. 5.6.5 The course provider shall notify each complainant or appellant in writing of the result of the

complaint or appeal and of the right to appeal against the result to NABET. 5.6.6 The course provider shall maintain records of all complaints and appeals, of their resolution

and the corrective & preventive actions taken. 5.7 Subcontracting of Courses & Branches

A subcontractor is any organization not owned by your organization or any person not employed by your organization that you give authority to administer or present your NABET registered course.

No NABET registered course can be subcontracted to a second organization, a person or course provider.

A Branch is an office/site owned and controlled by your organization and authorized to market, administer or present your NABET registered training course under your name, responsibility and control.

You should have appropriate methods to monitor and measure the performance of your branches to ensure that the NABET requirements are consistently met.

5.8 Confidentiality

5.8.1 The course provider shall have adequate arrangements consistent with applicable laws to safeguard confidentiality of all information provided by participants, including results of examinations. These arrangements shall be extended to include organizations or individuals acting on its behalf and representatives of the course provider.

5.8.2 Except as required in this criteria, information about a participant shall not be disclosed to a

third party without written consent of the participant, nor shall information about a participant’s sponsor be disclosed without written consent of the sponsor.

5.9 Changes 5.9.1 The course provider shall ensure that any major changes it intends to make to the training

course are first approved by NABET. 5.9.2 Following a decision on and publication of changes, the course provider shall verify that each

of its course instructors and branches carries out necessary adjustments to the course and materials before the agreed effective date


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5.9.3 The course provider shall notify NABET of any changes of address or any significant changes in organization structure or provision of services.

5.9.4 NABET reserves the right to carry out assessment of changes to the Documents and/or

course delivery before its approval. The expenses for this re-assessment shall be borne by the course provider.


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Section – 6 ASSESSMENT OF COURSE PROVIDER 6.1 Language All communications, documentation and records shall be in English. 6.2 Initial Assessment 6.2.1 Documentation assessment

6.2.1.1 NABET shall evaluate the documented system including (but not limited to):

a. Quality Manual

b. The course material, including the subjects to be covered, the time schedule for the various activities, and all the participant and instructor materials such as course notes, participant reading materials, case studies, simulations, tutor notes.

c. The examination format, questions and answers, time allotted, grading procedure,

pass/fail requirements, policy and procedures for examination, technique for continuous evaluation, procedures used to assure the quality of measurements.

d. The criteria for selecting instructors, procedures for assessing their performance and

a current list of instructors, their resumes and NABET registration status

e. Course administration documents including policies for admission of participants, course registration forms, fee schedules, course certificates and promotional material.

6.2.1.2 After the evaluation, NABET will inform the course provider of the non-conformities

and/or observations if any.

6.2.1.3 The course provider shall be required to close all observations and non-conformities before the next stage of assessment.

6.2.2 Course Assessment 6.2.2.1 Following review and acceptance of the documentation procedures, NABET shall undertake

at least one full assessment of the presentation of the course. NABET shall evaluate all aspects of the course and all activities of the instructors for conformance to the applicable NABET criteria & course providers’ procedures, and evaluation of participants for effective delivery of the course.

During the assessment of the course, NABET Assessor reserves the right to allocate training

session to the Tutors of the course. 6.2.2.2 The course provider shall be informed of the findings and non-conformities if any in the

closing meeting by the Assessor. However the final report and the recommendation will be sent after the decision of the Board.

6.2.2.3 In case any corrective action is required, the course provider shall make the necessary

corrections & improvements, and submit the appropriate documentation within a defined time schedule.

6.2.2.4 An additional full or partial evaluation of a course offering may be done by NABET to verify

the compliance of corrections. 6.2.2.5 The NABET Registration Committee will take the decision on NABET registration for the

course depending on the Course Assessment report.


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6.2.2.6 When NABET Registration Committee determines that the course provider’s presentation is

acceptable, NABET shall inform its approval to the course provider. This registration will be with effect from the first offering of the course, which was subjected to NABET assessment.

6.2.2.7 The annual registration fee should be paid by the course provider on receipt of invoice from

NABET. Subsequently for every year, the training course provider will have to clear the surveillance assessment and pay the requisite fee for renewal of registration.

6.2.2.8 A certificate will be issued on receipt of fees. 6.3 Surveillance and Re-assessment 6.3.1 Surveillance Assessment

6.3.1.1 To assess course provider’s continuing conformance to NABET criteria and the effective implementation of the course provider’s procedures, NABET shall normally conduct an annual surveillance for:

a) Administrative procedures, practices and records. b) A minimum (but not limited to) one-day surveillance of a course offering.

During the assessment of the course, NABET Assessor reserves the right to allocate training session to the Tutors of the course.

6.3.1.2 Course surveillance and audits of administrative procedures shall be planned to

ensure that different aspects of the course and the course provider’s system are regularly reviewed.

6.3.1.3 Course presentation surveillances shall review different instructors and different

venues. NABET reserves the right to demand witness of a specific Instructor.

6.3.1.4 NABET reserves the right to carry out more frequent or longer surveillance as necessary for specific course providers in case of complaints/concerns against the delivery or administration of the course. Cost for the same shall be borne by the course provider.

6.3.1.5 NABET may conduct surprise surveillance of the course offerings.

6.3.2 Re-assessment

6.3.2.1 NABET shall carry out reassessment of the office procedures, documentation and complete course offering to verify the compliance with the NABET criteria.

6.3.2.2 NABET shall inform the course provider in advance for the conduct of re-assessment.

6.3.2.3 The course provider shall apply in the requisite application form for the reassessment

of its course enclosing the necessary papers and the fee after three years from the date of initial registration.

6.4 Suspension or Cancellation 6.4.1 NABET may suspend or cancel an approval of the course because of any of the following, but

not be limited to:

a. non compliance or violation of the NABET requirements b. providing insufficient or incorrect information to NABET c. improper use of NABET registration and logo


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d. changes in the certificate format without NABET approval e. changes in the course material without NABET approval f. failure to report any major changes in the course g. any other condition deemed appropriate by NABET h. non payment of fees. i. At you request

All certificates of successful completion issued during the period of suspension must be cancelled and recalled.

6.5 Appeals 6.5.1 An appeal against NABET shall be made in writing to the Board Chairman. An Appeals

Committee will be constituted out of the Board Members to resolve the issue. 6.5.2 In case of non-acceptance of the decision of the Appeals Committee by the applicant, the

appeal can be made to the Secretary General, QCI, who will then appoint an arbitrator for the purpose. The arbitration shall be held in the city of Delhi and shall be in accordance with the Arbitration and Conciliation Act 1996.


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FEE STRUCTURE

(Hospitals & Healthcare Providers Accreditation Courses)

Training Course

Fee Details (in Rs.)

Awareness Course

a) Application Package 500/-

b) Application Fee 35,000/-

c) Assessment Fee 12,000/- per man day *(Course material - 1 day Administration - 1 day

Course delivery - 2 days) # plus actuals

d) Annual Fee (up to 12deliveries) payable in advance

25,000/-

e) Above 12 offering 2,000/- per course f) Surveillance

(every year) 12,000/- per man day *(Administration – 1 day

Course delivery – 1 day) # plus actuals

g) Re-assessment (after 3 years) Application Assessment

30,000/- 12,000/- per man day

*(Course material – 1 day Administration - 1 day

Course delivery - 2 days) # plus actuals


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GENERAL INFORMATION ON PAYMENT OF FEE FOR TRAINING COURSE ACCREDITATION

1. The fee is to be paid by a Demand Draft payable at Delhi or a local Cheque of Delhi in favor of “Quality Council of India”.

2. Only the Application fee is to be sent along with the application. Applications not accompanied by the application fee will not be considered.

3. The Annual fee is to be sent only after the receipt of confirmation from NRBPT. Certificate will be sent after receipt of full fees and expenses.

4. Annual fee is to be paid in advance before the beginning of the next year of certification.

5. The company has the option to pay the additional course fee offerings in advance based on their calendar of programmes or they may pay at the end of the year based on the number of programmes actually conducted. This will be verified during the surveillance audit.

6. “*” Indicates a typical example. The number of man-days may vary.

7. “#” Expenses on local travel, outstation travel, boarding and lodging etc. of Assessors will be charged on actuals.


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APPLICATION FOR

ACCREDITATION OF COURSES

1.

Name of the Applicant (Organization name)

................................................................................................................... ...................................................................................................................

2. Application for Name of the Course__________________________________________________

3. Address ............................................................................................................................................... ...............................................................................................................................................

Tel no ................................. (std code) (no.)

Fax no. ................................. (std code) (no.)

Email ........................................................

(The addresses of other branch offices should also be given. It can be attached as a separate sheet, with this application.)

4. The following documents are enclosed (two copies):

a) System Manual for the course including : I. Copy of the Course Material

II. Examination Paper (Sample)

III. Case Studies

IV. Any supporting notes/Tutor Material/Instructions etc.

V. Continuous evaluation formats

VI. Any other training material

VII. Administrative procedures

VIII. Instructor Qualification criteria and their evaluation procedures

b) List of Instructors with their resumes

c) Corporate Brochure and Course Promotion Material

d) Organisation structure & details of relationship with any certification body

e) Certificate and Letter of Attendance proposed to be issued to participants

f) Schedule of Courses (for next six months)

5. Please find enclosed the Demand Draft / Cheque (Delhi only) no. ___________for Rs. _____________dated __________ drawn on ____________ in favor of Quality Council of India, payable at New Delhi towards the application fee.

6. Authorized Signatory:

Name .........................................................................................................................................

Designation .........................................................................................................................................

Signature ...................................................................... Date .........................................

HL-01


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